What's Up Your Sleeve? A Scoping Review of White Coat Contamination and Horizontal Microbial Transmission

Ruba Sajdeya, MD; Akemi T. Wijayabahu, MS; Nichole E. Stetten, PhD, MPH; Omar Sajdeya, MD; Osama Dasa, MD, MPH


South Med J. 2022;115(6):360-365. 

In This Article

Abstract and Introduction


Objectives: White coats have been suggested to serve as fomites carrying and transmitting pathogenic organisms and potentially increasing the risk of healthcare-associated infections (HAIs). We aimed to examine the current evidence regarding white coat contamination and its role in horizontal transmission and HAIs risk. We also examined handling practices and policies associated with white coat contamination in the reviewed literature.

Methods: We conducted a literature search through PubMed and Web of Science Core Collection/Cited Reference Search, and manually searched the bibliographies of the articles identified in electronic searches. Studies published up to March 3, 2021 that were accessible in English-language full-text format were included.

Results: Among 18 included studies, 15 (83%) had ≥100 participants, 16 (89%) were cross-sectional studies, and 13 (72%) originated outside of the United States. All of the studies showed evidence of microbial colonization. Colonization with Staphylococcus aureus and Escherichia coli was reported in 100% and 44% of the studies, respectively. Antibacterial-resistant strains, including methicillin-resistant Staphylococcus aureus and multidrug-resistant organisms were reported in 8 (44%) studies. There was a lack of studies assessing the link between white coat contamination and HAIs. The data regarding white coat handling and laundering practices showed inconsistencies between healthcare facilities and a lack of clear policies.

Conclusions: There is robust evidence that white coats serve as fomites, carrying dangerous pathogens, including multidrug-resistant organisms. A knowledge gap exists, however, regarding the role of contaminated white coats in HAI risk that warrants further research to generate the evidence necessary to guide the current attire policies for healthcare workers.


The white coat, the symbol of purity and professionalism, has been at the center of controversy around its potential role in horizontal microbial transmission and healthcare-associated infections (HAIs). Current evidence suggests that white coats can serve as fomites, carrying and transmitting pathogenic microorganisms, including multidrug-resistant organisms (MDROs).[1,2] Contamination is believed to happen mainly when white coat sleeves come in direct contact with patients' bodies during physical examination.[1,2] Previous data showed that up to 37% of HAIs in intensive care units could be attributed to horizontal transmission,[3] and horizontal microbial transmission was associated with increased morbidity, mortality, and patient care costs among hospitalized patients.[4,5] Horizontal transmission refers to the spread of infectious agents from one individual to another through contact.[6] Because preventing HAIs has become a healthcare and public health priority,[3,7] there have been calls to adopt policies to remove the white coat from healthcare worker (HCW) dress codes. The white coat, however, carries a symbolic significance of trust and professionalism that is deemed irreplaceable for many patients and physicians,[8,9] and also has served as a protective shield for HCWs from potentially hazardous infectious agents, which has triggered opposition to white coat removal calls.[10]

The controversy also has been fueled by the inconsistent evidence linking white coat contamination with HAIs.[4,5] Some previous evidence has demonstrated that white coats can carry and transmit dangerous pathogens, suggesting a potential role in HAIs.[11–13] Others, however, considered the available evidence insufficient to support an association between transmission and increasing HAIs risk because carrying pathogens does not necessarily cause infection.[10] Nevertheless, organizations concerned with infection control, such as the Society for Healthcare Epidemiology of America, recommend taking cautious measures, including removing white coats during patient examination or direct patient contact.[14]

As the potential risk of HAI transmission through white coats needs to be further evaluated, there is no clear policy regarding white coat wearing in most healthcare settings. The purpose of this review was to critically examine the evidence on the potential role of white coat contamination in horizontal microbial transmission and HAIs risk to help inform HCW attire policies. We also aimed to evaluate current white coat handling practices and discuss key findings of existing studies.